What Is a Pre-Existing Condition?

Today, Jeff Hess, the ACA product specialist at Empower Brokerage, is coveringpre-existing conditionbecause some consumers are confused about what is considered a preexisting condition. Jeff explains some of the factors that categorized a condition as a pre-existing condition. For a comprehensive summary of pre-existing conditions, click here.

Definition

Pre-existing conditions all run on a basic scale across the board. Anything that has happened to you, anything that you’ve seen a provider for, anything that you take medication for, or anything that you’ve been diagnosed with counts as a pre-existing condition. Even something that you should have gone seen a doctor for, such as medical advice that would be pre-existing.

Examples

For example, we had a client we underwrote who answered “no” to everything. They claimed everything was great. Then, they ended up going to the doctor having problems with their knee. The doctor asked, “How long has your knee been locking up and swelling?” The client said for about 5 years. Roll the camera forward, their knee problems are classified as a pre-existing condition. That means that the visit would not be covered. Typically, that would not be covered no matter what type of treatment.

Pre-existing is anything that has happened prior to the policy. For instance, if I broke my leg 4 years ago, I would’ve needed surgery and rehab. If I ended up in the hospital again for the leg, that would not be a pre-existing condition. However, it also depends on the state and how far back they look, which varies. If I messed up my shoulder and needed rehab but no surgery, the rehab would be considered pre-existing in the 12 month period. If I re-injured my shoulder and have to go in and get surgery, surgery would not be covered because that is considered a pre-existing condition because I was already getting treated for it.

Since insurance is often times overwhelmingly confusing, we want to shed light on this industry by answering YOUR questions. If you have any questions or concerns, comment below and your question may be the topic of our next video! If you have any questions, please call us toll-free (888) 539-1633.